Reduction In Perinatal Mortality Rate Research Articles

What do the numbers say? - Introduction of the WHO ICD-PM classification and fetuses-at risk approach in perinatal audit, South India

Objective: In India, despite a reduction in perinatal mortality rate from 2014 to 2019, still birth rate is still the same at the national average of 4/1000 live births. As yet there is no nation-wide audit in India except for facility based audits. Hence the need for a simplified yet effective audit process exists. The aim of this study was to perform a qualitative perinatal audit and devise methods for future audits. Methods: We conducted a one year audit for all perinatal deaths using WHO ICD PM and 3-delay classification. Gestational age (GA) specific mortality was calculated for significant underlying factors using fetuses-at risk approach. Results: We recorded a perinatal mortality rate of 6.1/1000 births among booked cases and 21.32/1000 births among referred cases. Fetal growth restriction was the most common antenatal condition, accounting to 33.3% of antepartum deaths. Prematurity accounted to 52% of neonatal deaths. Phase 2 delay with delayed referrals in severe pre-eclampsia and Phase 1 delay with late visit (> 24 h) to hospital after experiencing absent fetal movements were the most common identifiable delays. Hypertension stood out to be the single most common risk-factor. GA specific mortalities, calculated using fetuses-at risk approach, show a peak mortality rate at 30 weeks, 37 weeks and 38 weeks in pregnancies with early-onset preeclampsia, severe fetal growth restriction and medically treated gestational diabetes respectively. Conclusion: The audit identified significant contributing factors to the mortality. ICD-PM and 3-delay classification was simpler and easier to apply with wide areas of opportunities for secondary analysis.

Reduction in Perinatal Mortality after Implementation of HBB Training at a District Hospital in Mali.

Mali has a high neonatal mortality rate of 38/1000 live births; in addition the fresh stillbirth rate (FSR) is 23/1000 births and of these one-third are caused by intrapartum events. The aims are to evaluate the effect of helping babies breathe (HBB) on mortality rate at a district hospital in Kati district, Mali. HBB first edition was implemented in April 2016. One year later the birth attendants were trained in HBB second edition and started frequent repetition training. This is a before and after study comparing the perinatal mortality during the period before HBB training with the period after HBB training, the period after HBB first edition and the period after HBB second edition. Perinatal mortality is defined as FSR plus neonatal deaths in the first 24 h of life. There was a significant reduction in perinatal mortality rate (PMR) between the period before and after HBB training, from 21.7/1000 births to 6.0/1000 live births; RR 0.27, (95% CI 0.19-0.41; p < 0.0001). Very early neonatal mortality rate (24 h) decreased significantly from 6.3/1000 to 0.8/1000 live births; RR 0.12 (95% CI 0.05-0.33; p = 0.0006). FSR decreased from 15.7/1000 to 5.3/1000, RR 0.33 (95% CI 0.22-0.52; p < 0.0001). No further reduction occurred after introducing the HBB second edition. HBB may be effective in a local first-level referral hospital in Mali.

Delivery as Trauma: A Prospective Time-Cohort Study of Maternal and Perinatal Mortality in Rural Cambodia.

The majority of maternal and perinatal deaths are preventable, but still women and newborns die due to insufficient Basic Life Support in low-resource communities. Drawing on experiences from successful wartime trauma systems, a three-tier chain-of-survival model was introduced as a means to reduce rural maternal and perinatal mortality. A study area of 266 villages in landmine-infested Northwestern Cambodia were selected based on remoteness and poverty. The five-year intervention from 2005 through 2009 was carried out as a prospective study. The years of formation in 2005 and 2006 were used as a baseline cohort for comparisons with later annual cohorts. Non-professional and professional birth attendants at village level, rural health centers (HCs), and three hospitals were merged with an operational prehospital trauma system. Staff at all levels were trained in life support and emergency obstetrics. Findings The maternal mortality rate was reduced from a baseline level of 0.73% to 0.12% in the year 2009 (95% CI Diff, 0.27-0.98; P<.01). The main reduction was observed in deliveries at village level assisted by traditional birth attendants (TBAs). There was a significant reduction in perinatal mortality rate by year from a baseline level at 3.5% to 1.0% in the year 2009 (95% CI Diff, 0.02-0.03; P<.01). Adjusting maternal and perinatal mortality rates for risk factors, the changes by time cohort remained a significant explanatory variable in the regression model. The results correspond to experiences from modern prehospital trauma systems: Basic Life Support reduces maternal and perinatal death if provided early. Trained TBAs are effective if well-integrated in maternal health programs. Houy C , Ha SO , Steinholt M , Skjerve E , Husum H . Delivery as trauma: a prospective time-cohort study of maternal and perinatal mortality in rural Cambodia. Prehosp Disaster Med. 2017;32(2):180-186.

Perinatal Mortality Rates and Risk Factors for Mortality among Zygotic Twins and Singletons in Japan, 1995-2008

Objective: We aimed to determine the perinatal mortality rates (PMRs) for monozygotic (MZ) twins, dizygotic (DZ) twins, and singletons, together with the associated risk factors for these PMRs. Study design: PMRs of zygotic twins and singletons were estimated using Japanese vital statistics from 1995 to 2008. Results: Declines were seen in fetal death rates [FDRs; defined as deaths after a gestational age of (GA) 22 weeks], early neonatal death rates (ENDRs), and PMRs from 1995 to 2008 to approximately 1/4–1/3 for DZ twins and to 1/2 for both MZ twins and singletons. ENDRs and PMRs were the lowest at maternal ages (MAs) of 30–34 years for MZ and DZ twins and at 25–29 years for singletons. Each mortality rate in singletons was significantly lower at 25–29 years compared with those at other MAs. PMRs were significantly higher for MZ and DZ twins than for singletons in each MA group, except when MA was ≥40 years for DZ twins. PMR was the lowest at GA of 37 weeks for both MZ (6.6) and DZ (3.0) twins but was the lowest at GA of ≥40 weeks in singletons (1.1). PMRs were higher for both MZ and DZ twins than for singletons, except for GA of <36 weeks. PMR was significantly higher for MZ twins than for DZ twins for all GAs, except when GA was ≥39 weeks. The recent increase in preterm birth (i.e., GA of <37 weeks, excluding fetuses delivered at GA of <22 weeks) was associated with a reduction in PMRs for both MZ and DZ twins. Conclusion: In this Japanese population, PMRs decreased for zygotic twins and singletons between 1995 and 2008. The most marked decline was for DZ twins.

Continuous objective recording of fetal heart rate and fetal movements could reliably identify fetal compromise, which could reduce stillbirth rates by facilitating timely management

Stillbirth currently affects approximately 1 in every 200 pregnancies in the United Kingdom. Fetuses may exhibit signs of compromise as part of a stress response before stillbirth, including reduced fetal movements (RFM) and fetal heart rate (FHR) alterations. At present, and despite widespread use, current fetal monitoring is not associated with a reduction in perinatal mortality rate (PMR) as signs of fetal compromise are not adequately detected. This may be attributed to inaccuracies resulting from manual interpretation of results or subjective assessment of fetal activity. In addition, signs of compromise often occur only hours or days before fetal death, so may be missed by current monitoring methods, which are performed intermittently. A significant consideration is that correct identification of these signs and consequent intervention can result in the delivery of a healthy baby, thus preventing stillbirth. A hypothesis is presented, proposing prompt detection of fetal compromise with the use of 24-hour continuous objective fetal monitoring. With focus placed on obtaining long-term FHR and fetal movement data, prior interest has been found in developing devices for this purpose. However, introduction into clinical practice has not been achieved. Investigation of the hypothesis will begin with the design of a device to record the mentioned parameters, followed by an appropriate validation process. Should development and testing be successful, an eventual comparison in PMR with the use of continuous fetal monitoring vs current monitoring would address the hypothesis. It is suggested that a timely yet reliable indication of fetal wellbeing obtained via long-term monitoring would allow prompt and appropriate obstetric intervention and consequently reduce PMR.

Prise en charge du dépassement de terme

The classic pregnancy term is between 37 and 42 weeks of gestation and the perinatal mortality and morbidity rates increasing progressively during this period, it is difficult to decide of an "ideal" term above which a medical intervention (induction of labour) brings more benefits than risks linked to the natural evolution of pregnancy. There is a good scientific evidence for the induction of labour from 41 weeks of gestation, defined like "postdating" term, when the cervical conditions are favourable (Bishop score>5) and systematically from 42 weeks (significative reduction of perinatal mortality rate and not increased rate of cesarean delivery compared with expectant management). An intensive antenatal surveillance involving a nonstress test and an evaluation of amniotic fluid volume is an efficient alternative when the conditions of delivery are unfavourable between 41 and 42 weeks of gestation or when the woman does not wish induction.

Trends in the modes of delivery and their impact on perinatal mortality rates.

To determine changes in the incidence of vaginal deliveries, cesarean sections, and forceps deliveries and their potential association with fetal, early neonatal, and perinatal mortality rates over time. A retrospective study was carried out and the occurrence of deliveries supervised by university services between January 1991 and December 2000 was determined. Data regarding fetal, early neonatal, and perinatal deaths were assessed using obstetric and pediatric records and autopsy reports. Of a total of 33,360 deliveries, the incidence of vaginal deliveries, cesarean sections, and forceps deliveries was relatively steady (around 60, 30, and 10%, respectively) while, at the same time, there was a marked reduction in fetal mortality (from 33.3 to 13.0 per thousand), early neonatal mortality (from 30.6 to 9.0 per thousand), and perinatal mortality (from 56.4 to 19.3 per thousand). The marked reduction in perinatal mortality rates seen during the study period without an increase in cesarean sections indicates that the decrease in perinatal mortality was not impacted by cesarean section rates. The plausible hypothesis seems to be that the reduction in perinatal mortality of deliveries performed under the supervision of university services was more likely to be associated with better neonatal care rather than the mode of delivery.

PERINATAL MORTALITY AND CHORIONICITY IN TWINS

Despite advances in both obstetrics and neonatology the perinatal mortality rate (PNMR) among twins still remains high, estimated as accounting for approximately 10% of all perinatal mortality. Perinatal mortality rates (PNMR) for England and Wales showed a dramatic reduction in perinatal deaths for multiple births over the 1950s to 1980s with a fall from approximately 90 to less than 50 per 1000 births. The Northern Region Perinatal Mortality Survey Steering Group also reported a significant reduction in twin PNMR between 1982 and 1994 from 55.4 to 44.4/1000 births. A similar decrease has also been noted in the Japanese twin population with a reduction in the PNMR between 1980 and 1998 from 91 per 1000 births to 31 per 1000. In Scotland between 1986 and 1990 PNMR for twins was 47 per 1000 approximately 4-5 times the rate in the singleton population. The higher preterm delivery rate in twins, either from spontaneous or induced labour, with its associated problems of prematurity remains the major cause of morbidity and mortality. Other factors, which contribute to the higher PNMR in twins include fetal growth retardation, intra-twin birth weight discordancy, fetal anomalies and problems specific to monochorionic twin gestations.

INCREASING CAESAREAN SECTION AND PERINATAL OUTCOME

An analysis of births by caesarean sections for ten years at a service hospital was carried out to identify the benefit in terms of reduction in perinatal mortality over the period without increase in maternal mortality and morbidity. An increase of 43.25 per cent in caesarean section rate was observed. Since 1986 there had been no significant change in the indications for caesarean sections or obstetrical care in terms of man and machine modernisation at this hospital. New born's care in this hospital is supervised by obstetrician and medical specialist. However, a definite reduction in perinatal mortality rate by 59.68 per cent was noted with no maternal mortality in caesarean cases. This retrospective study showed that the judicious increase of caesarean sections could improve perinatal outcome.

The epidemiology of perinatal death in Jamaica.

Information from the Jamaican Perinatal Mortality Survey was used to identify features of mothers and their pregnancies that were independently associated with perinatal death. Social, biological, environmental, life style and medical aspects of mothers and their pregnancies were collected on two inter-locking subsamples: (1) all births on the island of Jamaica in the 2 months of September and October 1986, the 'cohort months', and (2) all fetal deaths of weight 500 g or more, together with all neonatal deaths, in the 12-month period from 1 September 1986 to 31 August 1987. Singleton survivors from the cohort months were compared with all perinatal deaths in the 12-month period using logistic regression. The first model omitted items concerning past obstetric history, but these were included in the second model. In total, 21 variables entered the first model and 24 the second. The only item that became non-significant when past obstetric history was included was maternal age. The final model compared 1017 perinatal deaths with 7672 survivors. It consisted of the following: union (marital) status (married being at lower risk, P < 0.01), maternal employment status (housewives at lowest risk, P < 0.001), number of adults in household (the more the higher the risk, P < 0.05), the number of children aged < 11 (the more the lower the risk, P < 0.0001), use of toilet facilities (shared with other households increased risk, P < 0.001), maternal height (tall women at reduced risk, P < 0.001), mother's report that she was trying to get pregnant (P < 0.001), maternal alcohol consumption (drinkers had lower risk, P < 0.05), maternal syphilis (higher risk, P < 0.0001), bleeding before 28 weeks (higher risk, P < 0.0001), bleeding at 28 weeks or more (higher risk, P < 0.0001), first diastolic blood pressure (80 mm + at higher risk, P < 0.0001), highest diastolic blood pressure (100 mm + at increased risk, P < 0.0001), highest proteinuria (++ or more at increased risk, P < 0.0001), vaginal discharge/infection (untreated at increased risk, P < 0.001), pre-eclampsia diagnosed in antenatal period (increased risk, P < 0.01), maternal diabetes (increased risk, P < 0.05), start of antenatal care (first trimester at reduced risk, P < 0.01), iron taken (reduced risk, P < 0.0001), type of perinatal care available in parish of residence (reduced risk if consultant obstetricians and paediatricians available at all times, P < 0.0001), number of miscarriages and terminations (the more the higher the risk, P < 0.0001), previous stillbirth (higher risk, P < 0.0001), previous early neonatal death (higher risk, P < 0.001), previous Caesarean section (higher risk, P < 0.01). The implications for reduction in perinatal mortality rates are discussed.

Changes in the cause specific perinatal mortality rates by gestational age.

Perinatal mortality rates have been markedly reduced in Japan (Ministry of Health and Welfare, 1986). Perinatal deaths were most closely related to fetal age and weight. The infants of short gestational duration and lowbirth weight have been found to show high perinatal mortality rates (Erhardt et al., 1964; Yerushalmy 1970; Behrman et al., 1971). The reduction in perinatal mortality rates was greatest for large birth weight infants(Makino et al., 1985). Birth weight was as sociated with gestational age (Erhardt et al., 1964). Perinatal mortality by gestational age differed according to cause of death. Therefore, it is considered to be important to observe the changes in cause specific Perinatal mortality rates by gestational age. The purpose of this paper is to study the association between decrease in perinatal mortality rates and gestational age.

Perinatal mortality: the current debate.

Using the parliamentary 'Short Report' on perinatal and neonatal mortality as a focus for analysis, this paper attempts a critical examination of recent trends in perinatal health policy debate, and suggests a polemical explanation of such trends. The paper begins by outlining the major concerns of current debate and unravelling the assumptions and apparent contradictions in both 'official' and popular arguments. It then utilises a framework and perspective adopted by Lewis in her recently published analysis of Edwardian maternal and infant welfare policy, in an attempt to make sense of the major contradictions identified. The importance of considering the ideological 'ends' of social policy movements--in this instance, a restating of the ideology of motherhood--over and above purported societal 'needs'--i.e. a reduction in perinatal mortality rates--is highlighted.